Subsidence Questionnaire

Transcription

1 Subsidence Questionnaire To Ecclesiastical Insurance Office plc, Beaufort House, Brunswick Road, Gloucester GL1 1JZ You have a duty to present us with a fair presentation of the risks to be insured and must disclose every material circumstance which you know or ought to know about such risks. You do not need to disclose circumstances which reduce the risk or those which the Company already knows or ought to know. If you breach your duty to provide a fair presentation of the risks to be insured, the policy could be cancelled or terms changed in accordance with the policy conditions. Please complete in BLOCK CAPITALS and tick where indicated General Information Name of applicant(s) Name of establishment to be insured Full address(es) of the premises to be insured Postcode: Telephone: 1 Please state date on which this insurance is to commence te: this insurance will not be, or continue to be, in force until this application form has been accepted by the Company 2 What is the age of the property s (a) main structure? (b) extensions or additions?

2 3 Was a structural survey or Building Society valuation carried out before or after purchase of the property? If please supply a copy of the report 4 (i) Have there been any incidents of structural movement of any kind, e.g. subsidence, heave or landslip: (a) at the property? (b) in the adjacent properties? (ii) Are there any visible signs of: (a) damage to the property caused by subsidence? (b) repair following such damage? If to either of these questions please give details below 5 Have the foundations and/or floor slabs required structural repair or underpinning at any time? If please give details below te: Please also enclose copies of any reports, plans or specifications you have which provide information relevant to these repairs. These will be returned to you if you so request 6 Has the Local Authority made any special provisions regarding the design and construction of foundations and/or floor slabs at the property? If please give details below te: Please also enclose copies of any reports, plans or specifications you have which provide information relevant to these repairs. These will be returned to you if you so request

3 7 Is the property: (a) situated in the vicinity of (i) railways? (ii) underground waterways? (actual or proposed) (iii) watercourses? If please give details and distance (in metres) below (b) constructed on (i) made up ground? (ii) an infill site? If please give details below 8 (a) are there any of the following trees within 15 metres of the property? (please tick) Poplar Willow Lime Oak Elm (b) Are there any other trees within 10 metres or less than half their own height away from the property? (c) Have any trees been removed within the last 3 years which fall within the above categories (a) or (b)? If please give details below 9 Is the property currently insured against the risks of subsidence, heave or landslip? If please detail the reason(s) why this cover is now being sought below

4 10 Are there any special reasons giving rise to the request for subsidence cover? If please give details below 11 In respect of the risks of subsidence, heave or landslip proposed for this property has any (a) loss or damage arisen during the last 5 years whether insured or not? (b) company or underwriter declined to issue or renew a policy or impose special terms? If to either of these questions please give details below Law applicable It is our intention to apply the law of England and Wales to your insurance contract unless your business is located in Scotland in which case the law of Scotland will apply. If there is any dispute as to which law applies, it will be English law. Fraud prevention We may check your details with various fraud prevention and credit reference agencies. If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies. Law enforcement agencies may access and use this information. If you make a claim, we will share your information (where necessary) with other companies to prevent fraudulent claims. For further information please refer to our Privacy Policy at

5 How we will use your data We hold data in accordance with the Data Protection Act It may be necessary for us to pass data to other organisations that supply products and services for this policy. Additional information If you require more space for any of your answers please use the space below and if necessary continue on the separate sheet.

6 Declaration I/We confirm that as far as I am/we are aware the statements made by me/us or on my/our behalf in connection with this insurance are true and complete. I/We agree to accept a policy in the Company s usual form for this class of business. Signature Name and Position On behalf of Applicant Date Signature Name and Position On behalf of Applicant Date Beaufort House, Brunswick Road, Gloucester GL1 1JZ Ecclesiastical Insurance Office plc (EIO) Reg is registered in England at Beaufort House, Brunswick Road, Gloucester, GL11JZ, UK and is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Ecclesiastical Insurance Office plc 2019 PD /19